			<form id="addrequestform5">
				Amount: <input type="text" id="amount" name="amount"/><br />
				Mode of Payment: 
				<select id="mode" name="mode">
					<option>Cash</option>
					<option>Check</option>
					<option>Bank Transfer</option>
				</select><br />
				Date Received: <input type="text" id="date_received" name="date_received" /><br />
								 <script type="text/javascript">
					$(function() {
						$("#date_received").datepicker({ dateFormat: 'yy-mm-dd' });
					});
				</script>
				Receipt Number (if applicable): <input type="text" id="receipt_no" name="receipt_no"/><br />
				Short message for the management: <br /><textarea id="message" name="message">Enter short message here.</textarea><br />
				<input type="submit" value="Send Request" onclick="if($('#addrequestform5').valid()){sendRequest()}" />
			</form>